Provider Demographics
NPI:1205186715
Name:24 ON PHYSICIANS, P.C.
Entity Type:Organization
Organization Name:24 ON PHYSICIANS, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP/SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:DAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-740-0895
Mailing Address - Street 1:PO BOX 849318
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02284-9318
Mailing Address - Country:US
Mailing Address - Phone:770-740-0895
Mailing Address - Fax:770-740-0896
Practice Address - Street 1:1500 S LAKE PARK AVE
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6638
Practice Address - Country:US
Practice Address - Phone:770-740-0895
Practice Address - Fax:770-740-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2016-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty